8
University
Center
for
Academic
and
Workforce
Development
SCHENECTADY
SUNV
UCAWD
SCHENECTADY COLLEGE & CAREER OUTREACH CENTER (SCCOC)
APPLICATION FOR ADMISSION
IN ADDITION TO THE INFORMATION IN THIS FORM, YOU WILL NEED TO PROVIDE PROOF OF RESIDENCY, EDUCATIONAL
BACKGROUND, AND INCOME IN ORDER TO RECEIVE SERVICES
IDENTIFICATION INFORMATION
Date: SSN: DOB:
Name:
(Last) (First) (Middle) (Suffix e.g. Jr., Sr.) (Previous Last Name)
Mailing Address:
(Street, Apt # / PO Box) (City) (State) (Zip) (Country)
Alternate (Permanent) Address:
(Street, Apt # / PO Box) (City) (State) (Zip) (Country)
Home Phone: ( ) Cell Phone: ( )
Email Address:
PARENT / GUARDIAN INFORMATION
If you are under 21 years of age and do not reside with a parent or legal guardian, please provide the
following information for a parent or legal guardian.
Name:
(Last) (First) (Middle) (Suffix e.g. Jr., Sr.)
Mailing Address:
(Street, Apt # / PO Box) (City) (State) (Zip) (Country)
Home Phone: ( ) Cell Phone: ( )
EMERGENCY CONTACT INFORMATION
Please provide contact information for an emergency contact.
Name:
(Last) (First) (Middle) (Suffix e.g. Jr., Sr.)
Phone: ( ) Relationship:
BIOGRAPHIC INFORMATION
Gender: ( ) Male ( ) Female Marital Status: ( ) Unmarried ( ) Married
SCCOC APPLICATION FOR ADMISSION PAGE 1
Are you a New York State resident? ( ) Yes ( ) No
If yes, but for less than one year, how many months?
Are you a U.S. Citizen? ( ) Yes ( ) No
If no, are you a Permanent Resident? ( ) Yes ( ) No (Please provide Alien Registration Number)
Have you served in the U.S. Military? ( ) Yes ( ) No
Are you Hispanic/Latino? ( ) Yes ( ) No
What is your race? (Choose all that apply)
( ) American Indian / Alaskan Native ( ) Asian ( ) Black or African American
( ) Native Hawaiian or other Pacific Islander ( ) White
EDUCATION BACKGROUND
High School Attended:
City: State:
Did you graduate? ( ) Yes ( ) No Highest grade completed:
Did you earn your High School Equivalency? ( ) Yes ( ) No
Date of Graduation/Completion:
College Attended:
City: State:
Did you graduate? ( ) Yes ( ) No Number of Credits Earned:
Have you previously been enrolled in EOP, HEOP, SEEK or College Discovery? ( ) Yes ( ) No
Do you have limited English proficiency? ( ) Yes ( ) No
Do you have limited reading ability? ( ) Yes ( ) No
EMPLOYMENT / INCOME INFORMATION
Are you currently employed? ( ) Yes ( ) No If yes, ( ) Full Time ( ) Part Time
What is your approximate annual household income?
Are you a Single Head of Household? ( ) Yes ( ) No
How many people reside in your household?
SCCOC APPLICATION FOR ADMISSION PAGE 2
SUPPLEMENTAL APPLICATION
Who referred you to the Schenectady College and Career Outreach Center?
Are you able to use the computer/internet on your own? ( ) Yes ( ) No
What is your primary goal in coming to the SCCOC? (Please check one)
( ) Earn a college degree ( ) Earn High School Equivalency (TASC)
( ) Job Search / Job Seeking Skills ( ) Vocational Skills
( ) Career Planning ( ) Improve Math Skills
( ) Cover Letter Preparation ( ) Improve Life Skills
( ) Resume Preparation ( ) Improve Math Literacy
( ) Other:
How many dependents do you have?
Do you have a criminal background? ( ) Yes ( ) No
Are you receiving any of the following services? (Check all that apply)
( ) SNAP (Food Stamps) ( ) Safety Net
( ) Temporary Assistance for Needy Families ( ) Other Public Assistance:
( ) Section 8 Housing ( ) Public Housing
Are you a Section 8 resident? ( ) Yes ( ) No
Are you a Schenectady Municipal Housing resident? ( ) Yes ( ) No
Are you classified as:
( ) Single Head of Household ( ) Dislocated Worker ( ) Displaced Homemaker
DO NOT WRITE BELOW THIS LINE (STAFF USE ONLY)
Residency Documentation:
Education Documentation:
Income Documentation:
Student Banner ID #:
Online Skills Connect ID: Password:
Staff Initials:
SCCOC APPLICATION FOR ADMISSION PAGE 3
General Release Form
I authorize the Schenectady College and Career Outreach Center to use my photographic image(s) or
video graphic image(s) for news releases and/or feature stories, where it may assist the Center to
fulfill its mission and/or aid the Center in promoting its services.
Print Name Date
Signature
I authorize the Schenectady College and Career Outreach Center to use my name in the media for
news releases and/or feature stories where it many assist the Center to fulfill its mission and/or aid
the Center in promoting its services.
Print Name Date
Signature
I respectfully request that neither my name nor my photograph be used to assist the Center to fulfill
its mission and/or promote its services.
Print Name Date
Signature
SCCOC APPLICATION FOR ADMISSION PAGE 4
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